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Issues for the Anaesthetist
Analgesia during labourChoice of anaesthesia for CSEffect of drugs for PIH on the anaestheticFluid managementCoagulopathy & regional anaesthesiaThe difficult airway & intubationObtunding the hypertensive response to intubationManagement of an Eclamptic fitPostoperative care & ICUThe multidisciplinary team & protocols
ANAESTHESIA for CS
An unstable pre-eclamptic should NOT beanaesthetised for a CS unless there is an
immediate threat to her life.Eg .massive haemorrhage
STABILISE the patient FIRST
WHICH DRUGS ARE USEFUL
TREATING BP! DOES IT HELP?Methyl-dopaHydralazineLabetalolNifedipineSodium NitroprussideGlycerol trinitrate
Preventing & treating fits
What drugs can you use ?Magnesium SulphateDiazepamPhenytoinChlorpromazinePhenobarbitoneThiopentone
POLYPHARMACY?
Choice Determined By….
Maternal conditionFetal conditionThe indication for caesareanThe urgencyFacilities & equipment availableExperience of the anaesthetist
REGIONAL ANAESTHESIA
Often the safest choice for mother and baby
May be appropriate even in a ‘controlled’ eclamptic
Risk of Hypotension over-estimated and usually associated with hypovolaemia & antihypertensive agents
Difficult & Unwise in an obtunded, unconscious, agitated or convulsing patient
Spinal Haematoma
Incidence with normal coagulation:5 per million with spinal7 per million with epidural
Risk may be higher in pre-eclampsia because:
Coagulation in pre-eclampsia may be derangedPlatelet count may be reduced
Consequence may be permanent neurological damage
Balance tiny risk of peripheral neurological damage against the significant risk of hypoxic brain damage or death
GENERAL ANAESTHESIA
Stable operating conditions airway secure & convulsions attenuatedbut beware ……..
Difficult airway to maintain & intubateRisk of regurgitation & aspirationSevere hypertension on intubation may cause strokeHypotension due to drug interactionMuscle relaxant action may be prolonged
General or Regional ?
Regional generally considered safer than GA
Fetal emergency may suggest GA but maternal risk favours SPINAL
Need to balance the risk of mother & baby
GA usually reserved for cases where Regional is contraindicatedE.g. Uncontrolled Eclampsia
Who needs ICU /HDU?
Patients with:Airway obstruction Uncontrolled convulsionsPersistently lowered GCS (<8)Severe uncontrolled hypertensionCardio-respiratory problemsAdditional obstetric complications such as haemorrhage